Reconsidering Riskby Katherine Jensen, CNM

Risk assessment is an integral component of midwifery care. As long as I've been in practice, some sort of form has been in use to determine a pregnant client's "risk" for complications. If a client scores under a certain number, she is "low-risk." If she scores over a certain number, she is "high-risk."

There is nothing in between.

From my perspective, the "nothing in between" makes this system fundamentally incorrect. Yet, though I have questioned this practice for years, many of us, including me, continue to use these tools as if they could truly predict complications.

During one of the site visits for our accredited birth center, a visitor suggested we implement a risk assessment score, to be recorded at each appointment. She reasoned that since we were actually doing a risk assessment at each appointment, we should write it down. Documentation, after all, is what we are supposed to do, in abundance. Our birth center immediately complied, creating one more column on our prenatal log to record a risk assessment score for each appointment.

How do these risk assessment instruments actually affect the practice of midwifery?

Such tools were designed to direct our greatest attention to the pregnant women most in need of our professional abilities. The concept is appealing. Every pregnant client we see, we assess. Each appointment we are looking for any indicators that might suggest a developing problem. When the dots match up, "BINGO!" We've identified a problem, and the client is transferred out of midwifery care, or, in the best of situations, is co-managed.

However, I have come to understand over 30 years of practice that these risk assessment scores actually predict very little. If "over 5" is high risk and the components of a woman's score are: 1 for expecting a first baby, 1 for being low-income, 1 for having a parent with diabetes, 1 for smoking and 1 for having drunk a glass of beer before the positive pregnancy test, is this woman really high-risk? Does she need care by a physician to prevent problems from developing? Or does she need the loving, supportive care of a midwife more than at any other time in her life?

Or, let's say she starts out with a risk assessment score of 2: 1 for expecting a first baby and 1 for being low-income. But at her 36-week assessment she gets 2 for gaining only 19 pounds and another point for having an abnormal Pap. Now she's 5 and high-risk. Really? Does this woman need a physician to complete her care safely?

In tracking my own practice for over 20 years, I have found that the vast majority of women with risk scores over 5, which makes them high-risk in the system I use, have normal pregnancies and normal births with healthy babies.

We need to rethink risk assessment. How can it be that there are only two categories? Pregnancy is not a state of being either low-risk or high-risk. Why should we continue to use a system in which the majority of women who score in the high-risk category seldom develop any complication and many who score low-risk develop life-threatening conditions?

I suggest considering "risk potential." We don't even have to rewrite the systems, just our way of viewing and utilizing the numbers and our response to them. A woman with a risk assessment of 2 has a different risk potential than a woman who has a risk assessment of 7. Neither woman may develop any of the conditions for which she received her score. In fact, the woman who received the score of 2 because it was her first baby and she was low-income may develop fulminating pregnancy-induced hypertension and spend a week in ICU, while the woman scoring 7 because she's had a previous cesarean and plans a VBAC (we'll pretend that's still an option for the moment) AND is low-income and weighs 210 pounds may have the most wonderful waterbirth ever recorded.

Every practicing midwife knows that those two extremes are not the slightest bit rare. So why do we keep using a system that truly tells us so little? In some physician/midwifery practices, the midwives are only "allowed" to see the low-risk clients, under this scoring system.

Here's another radical notion. The higher the risk, the more likely it is that the woman will benefit from midwifery care. A woman who scores high in her risk potential is usually scared. That's a midwifery specialty. Why should the women who would most benefit from the midwifery model of care be denied that opportunity by practice protocols that demand transfer of care to a physician if the risk assessment score places the woman in the either/or high-risk category?

Midwives are the experts of normal birth and all its many variations. We tend to also be the experts in caring. Every woman deserves the care of a midwife, if that is the care she chooses.

In many medical communities, consultation, collaboration and, especially, transfer-of-care of a pregnant client who develops a real and serious problem is seen by physicians as "dumping" a problem in their laps-a problem that may get them sued. However, for the truly evolved soul who is neither terrified of a malpractice suit or sensitive about "territory" and financial gain, the impact of midwifery care for women with high risk potential may actually result in significantly lowered morbidity and mortality for both mother and baby. If a problem actually occurs, the expertise of the physician is available to deal with that problem, but where the high risk remains only a potential, every woman stands to gain by the expert care of a midwife.

Let's rethink risk assessment. The potential for problems may be real, but until they occur, the midwife remains the true expert.

Katherine Jensen works in the Pacific Northwest. She and eight other women put together an independent nurse-midwifery practice and a freestanding birth center, which they operated for six years before medical politics closed them down. Katherine remains absolutely committed to the radical notion that pregnancy and birth are normal and that a woman has a fundamental right to choose where she will birth and who will attend her.